Going beyond demographics: self-efficacy as a pivotal determinant in health communication and social marketing campaigns
II Self-efficacy as pivotal determinant
III Self-efficacy in health communication and social marketing campaigns
IV Self-efficacy and physical activity
V Self-efficacy across lifespan
-- submitted by Sophie Rosa
Audience segmentation is a defining step in health communication planning; identifying the characteristics of the key messages and communication approaches that will resonate with your priority population will ensure optimal impact. In fact, audience segmentation, based on a comprehensive audience analysis, should inform every decision in campaign planning and implementation, from objective setting to the choice of communication vehicles. Audience segmentation involves breaking down a large audience into a smaller number of subgroups that are as homogenous as possible on the basis of common characteristics. Segmentation allows you to specifically tailor your messages and approaches to reach more effectively a cluster of your broader population that requires special attention.
However, one of the most common mistakes in audience segmentation is basing it on demographic data alone; variables such as age, gender and education are not, on their own, reliable predictors of health behaviour change. As such, audience segmentation combining demographic, behavioural and psychographic data will maximize the resonance between the priority population and the campaign’s appeal. Psychographic and behavioural data are qualitative rather than quantitative; they provide context and inform the appeal health messages should adopt for maximum impact. Psychographic variables consist of values, beliefs, goals and lifestyles, whereas behavioural variables include self-efficacy, perceived susceptibility, skills level, readiness for change and benefits. In the last decades, evidence consistently demonstrated the ability of psychographic and behavioural variables in predicting health behaviour change; more specifically, on how key messages and material development and dissemination can be tailored to how the segments of the priority population fare on these variables in order to maximize impact.[1,2,3,4,5]
II Self-efficacy as pivotal determinant
Evidence from the last two decades has consistently shown self-efficacy as a pivotal determinant of health behaviour change. [6,7,8,9,10,11] Perceived self-efficacy is the belief in one’s ability to influence events that affect one’s life and successfully plan, set in motion and execute a course of action that's required to reach a goal.  Bandura introduced self-efficacy in the early 1990s, suggesting this core belief is the basis of human motivation, functioning, achievements and emotional well-being.  It is also a key construct that has been present in several popular health promotion theories – social cognitive theory, protection motivation theory and theory of planned behaviour.
Self-efficacy is one of the four social cognitive theory constructs brought forward by Bandura, the others being knowledge of health risk (susceptibility), outcome expectations and goal setting. While knowledge of health risk is known to be a precursor to health behaviour change, self-efficacy has been demonstrated to be a significant determinant that facilitates the translation of intentions into action and behaviour change. Individuals with high perceived self-efficacy believe they have the ability and the power to adopt healthy behaviours or give up unhealthy habits; this belief is the very foundation for both the motivation to make a positive change and behaviour change initiation. Self-efficacy also indirectly affects behaviour change by having an effect on other key determinants, such as goal setting, outcome expectations, perspective on challenges and barriers, etc. For instance, high self-efficacy will lead to realistic, achievable and higher goals with greater outcome expectations, which in turn will facilitate behaviour change. On the other hand, individuals with low self-efficacy will not only be convinced they lack control over their health, they will also see any effort as futile and view themselves as lacking the skills to surmount barriers.
III Self-efficacy in health communication and social marketing campaigns
Self-efficacy becomes particularly pertinent in health communication and social marketing campaigns aiming to increase healthy behaviour change. Two longitudinal studies of health communication campaigns reported that perceived self-efficacy regulates how effectively a perceived risk will lead to a search for additional health knowledge, and how effectively this newly acquired health information will in turn lead to behaviour change. [14,15] Numerous studies examining moderators and mediators of health behaviour change reported self-efficacy as the key mediator in interventions aiming to increase physical activity, [16,17,18,19] promote and support smoking cessation, [20,21] treat addiction [22,23, 24] and numerous other health behaviours. Another study demonstrated that of the four possible mechanisms through which campaigns can lead to behaviour change (information transmission, fear appeals, perceived vulnerability, and self-efficacy), self-efficacy was the most effective for both the adoption of new healthy behaviours and reduction of unhealthy habits, more so than fear appeals. 
The use of social media platforms further enhances how health communication campaigns can increase self-efficacy. Social media allows for easy dissemination of a variety of tailored messages, enables peer-to-peer discussions, allows modeling of healthy behaviours and provides problem solving and coping strategies effectively and quickly. Evidence suggests that social media platforms are a significant and valued source for encouragement, experience sharing, and motivation when it comes to adopting a healthier lifestyle, all of which lead to increased self-efficacy. [26,27,28,29] However, the capacity of social support to enhance self-efficacy hinges on its nature; social support that encourages dependence will undermine self-efficacy, whereas social support that fosters self-management and coping abilities will significantly boost self-efficacy. [30,31] Furthermore, interactive computer-assisted feedback presents unlimited potential for information sharing, dissemination of personalized motivating prompt and skill building interventions tailored to self-efficacy levels, and specific determinants of self-efficacy.
According to Bandura’s dual path of influence model, health communication and social marketing campaigns should balance both a large-scale approach and tactics tailored to the self-efficacy levels of priority population segments.  Large-scale untailored health communication and social marketing campaigns can be successful with individuals with high levels of self-efficacy and positive outcome expectations, as they can adopt or change behaviours with minimal external guidance. However, such campaigns do not have as significant impact for individuals who have doubts about their ability or the potential benefits of their efforts. Individuals that do not fully commit and would likely give up easily require additional external guidance to set up the necessary self-management structures to make any meaningful change in their lifestyle. Bandura’s dual path of influence model proposes that for segments with lower self-efficacy, health communication and social marketing campaigns must focus on tailored guidance, personal motivation and available social and environmental support.
IV Self-efficacy and physical activity
Bandura’s dual path of influence model can be further explained by examining the effect of self-efficacy on physical activity behaviours. Williams and French published a meta-analysis clearly demonstrating self-efficacy as a significant predictor of physical activity behaviour.  The review demonstrated that when an intervention included techniques to increase self-efficacy it led to increased effect size for physical activity. Of the 20 intervention techniques examined in the review, three specific techniques were significantly associated with both increased self-efficacy and physical activity behaviour (action planning, reinforcement of progress, provision of instructions/options). On the other hand, two techniques were associated with low self-efficacy and physical activity effect size (set graded tasks, relapse prevention).
The authors found that interventions aiming to assist subjects in identifying when, where and how they will be physically active led to increased self-efficacy and physical activity behaviours. Specific goal setting, as opposed to having the general goal ‘be more physically active’ resulted in significant increase in self-efficacy by providing clear actions and steps to be completed by subjects. In turn, success in completing the steps amplified commitment to the goal and strategy, which led to increased physical activity behaviours. The authors suggested that goal setting has a significant impact on the ability to translate intentions into behaviours in the initial stages of behaviour change.
Reinforcement of progress, such as positive feedback, praise, and focusing on small achievements and continual progress, was reported to increase self-efficacy and physical activity behaviour, as opposed to only rewarding the achievement of the final goal. According to Bandura, success in personal performance greatly increases perceived self-efficacy, which is critical in the initial stages of behaviour change – when subjects had not fully gained control of the behaviour and were not confident in their ability to stick with the strategy and to reach their goals.  Rewarding the achievement of the final goal, the authors suggest, will facilitate self-efficacy and physical activity behaviours maintenance, but only when the key milestones of behaviour change have been reached.
Communicating physical activity options and information on environmental support available to subjects increased both self-efficacy and physical activity behaviours. Motivating subjects to change their behaviours was reported to be useless unless they were knowledgeable of the appropriate resources and environmental supports available to assist them in putting their strategies into motion. Bandura suggests that social linking via the promotion of success stories and modeling is an effective means to link individuals to the available resources to be physically active and be provided with continued support and guidance.  The authors confirmed Bandura’s notion, reporting that interventions facilitating social comparison significantly increased physical activity.
The authors found that interventions encouraging a continual increase in behaviour difficulty were associated with lower self-efficacy and physical activity effect size. Although the authors offer evidence that breaking down a goal into achievable sub goals increases perceived self-efficacy, increasing the level of difficulty of the physical activity tasks (e.g., increase duration or level of exertion) may compromise initial self-efficacy and physical activity effort if the increase is encouraged before the subjects master the behaviour change or feel confident they can accomplish the new task.
Interventions that included relapse prevention techniques encouraging subjects to identify barriers and coping strategies to overcome them were also associated with lower self-efficacy and physical activity effect size. The authors suggest that focusing on barriers and potential failure likely undermines the subjects’ confidence that they can successfully fulfill the tasks or keep up with the strategy. Discussions around successfully achieving goals should focus on how and why the subjects will be capable of performing the behaviour, as opposed to what will derail them from their strategy. The authors point out however that their review focused on initiating physical activity behaviour change, and that for cases where a behaviour must be abstained from, relapse prevention techniques are essential to increase self-efficacy and chances of successfully resisting triggers or stopping the behaviour.
V Self-efficacy across lifespan
The significance of self-efficacy in acquiring and sustaining healthy behaviours or in preventing the adoption or maintenance of unhealthy ones has been demonstrated in various age groups, from childhood to senior years. There isn’t an age at which individuals cannot positively affect their well-being by gaining confidence in their ability to improve their circumstances and behaviours.
In childhood, self-efficacy is a key player in prevention and in the establishment of self-regulatory skills and healthy lifelong habits. Childhood is a time when the slate is relatively clear of deeply-entrenched unhealthy habits and the perfect time to develop decisional power and self-management skills. As such, health communication and social marketing campaigns targeting children must go beyond merely educating about the right choices to make and focus on raising children’s self-efficacy levels and building the necessary skills that will allow them to navigate the emotional and social pressures they will face in their formative years.
Interactive video games developed specifically to raise children’s perceived self-efficacy in managing chronic health conditions have been successful in significantly reducing complications from poor disease management. For instance, in role playing video games designed specifically for children suffering from diabetes, asthma or cystic fibrosis, children advance through the different levels as they become experts in managing the various triggers and risk factors related to their condition. Studies report a significant reduction of emergency asthma attacks as well as a 77% reduction in emergency visits by diabetic children at a six-month follow-up. [36, 37]
A considerable number of studies support self-efficacy as a core determinant of health behaviour and injury and substance abuse prevention in teenagers. Recent evidence shows that increasing self-efficacy is an effective means to prevent or reduce eating disorder attitudes and behaviours. [38,39] There is also growing evidence indicating self-efficacy as a core component of effective suicide prevention and alcohol abuse prevention initiatives in high schools. [40,41] The level of perceived self-efficacy is significantly associated with drinking intentions and behaviour by moderating the detrimental effects of descriptive norms and peer pressure. [42,43] Numerous studies, including a comprehensive meta-analysis, suggest that self-efficacy leads to increased condom use in sexually active adolescents and young adults. [44,45]
In seniors, self-efficacy is correlated with postural steadiness and mobility in older women, and it is also considered among the most important determinants for quality of life in seniors. [46,47] Another study showed a significant association between self-efficacy and walking habits (number of daily steps taken and enhanced gait) and improved balance. 
Self-efficacy is recognized as a focal determinant in managing one’s health; although feeling of susceptibility and core motivation to change are precursors to health behaviour change, individuals must acquire confidence in their ability to successfully manage their lifestyle and exert control over their health. However, population health extends far beyond individual lifestyle changes; social systems must also take the necessary steps through sound health policy development and supportive environments to assist individuals in organizing and executing the necessary course of actions that will lead to a healthier lifestyle.
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